Patients who have diabetes can take more active roles in their care and improve glycemic control by using a personal digital assistant preinstalled with special software, according to Dr. Samuel N. Forjuoh.
Dr. Forjuoh is leading a team of researchers who are examing the benefits of personal digital assistant (PDA) use with outpatients, with the goal of leveling the self-care playing field across socioeconomic groups.
However, their recently published pilot study showed although it is feasible to incorporate PDA use in diabetes self-care, it also poses challenges, said Dr. Forjuoh, professor of family and community medicine and director of research at the Scott and White Memorial Hospital in Temple, Tex.
An initial cohort of 43 subjects was provided with Diabetes Pilot software for Palm handhelds (J. Am. Board Fam. Med. 2007:20:375-84). Diabetes Pilot is made by Digital Altitudes LLC, Arlington Heights, Ill. The system enables users to record glucose measurements, insulin, and other medicines; meals; exercise; blood pressure; test results; and other notes, according to the Diabetes Pilot Web site. Among other things, the software tracks the intake of carbohydrate, calories, fat, protein, fiber, sodium, cholesterol, and other nutrients, and allows users to see trends in blood sugars with various reports and graphs.
Nineteen participants dropped out of the study; 6 more did not return and/or could not be reached after several attempts.
The 18 participants who completed the PDA intervention had a mean drop of 18% in hemoglobin A1c (HbA1c), from 9.7% at baseline to 8% after 6 months, Dr. Forjuoh said in an interview. Further updated results of the study, including data on exercise, foot care, and diet, are contained in a manuscript that has been accepted for online publication this May in Telemedicine and e-Health.
“The more a patient used the PDA, the greater the drop in HbA1c,” he said, noting that other researchers have documented comparable reductions in blood glucose associated with PDAs or similar technology.
The 18 finishers had an average age of 58 years. The group comprised 56% women, 56% Caucasians, and 38% college graduates. Also, 72% had annual family incomes of $30,000 or more, said Dr. Forjuoh. “[Most] of the patients in this pilot study were at the upper end of computer literacy, and it's apparent that only those who are comfortable using a PDA will benefit.”
The researchers are about to launch a larger study of 400 patients drawn from 14 Scott and White Health System clinics. The cohort will be assigned to four arms: a PDA-only group, PDA plus chronic disease self-management classes, self-management classes alone, and a usual-care group. In addition, the participants will be representative of the Central Texas population with respect to race, ethnic group, income, location, and insurance status, said coinvestigator Jane N. Bolin, Ph.D.
“We want to see if we can use PDAs to reduce health disparities in the population, and we'll also do a cost analysis that will determine how many health care dollars can be saved for every unit reduction of HbA1c,” said Dr. Bolin, director of the Southwest Rural Health Research Center, a branch of the Texas A & M University System Health Science Center, School of Rural Public Health in College Station.
In the pilot study, the researchers found that many patients were discouraged by the tedious task of tracking dietary effects on glucose by entering into the PDA all the foods they had eaten. The complaints and potential for further loss of participants led them to relax the rules on data entry. To make data entry easier, the vendor has been asked to fine-tune the software in time for the upcoming trial, Dr. Forjuoh said.
The cost per participant in the pilot study was $650, but because that included expenses that patients would not normally bear, Dr. Forjuoh estimates the actual cost per patient at around $300; the larger study with comparison groups is expected to settle that point, he said.
The spotty availability of reimbursement for such programs also curbs the widespread adoption of self-management technology, he said. “Many states don't require insurance companies to provide reimbursement for nutritional education and diabetes self-management education” so patients depend on clinics, “and eventually they end up in the emergency room.”
Neither Dr. Forjuoh nor Dr. Bolin reported financial conflicts.
Researchers hope PDA use can extend to patients across all socioeconomic levels. Courtesy Dr. Samuel N. Forjuoh